Scenario Capacity for Consent

Your client is sharp as a whip. They have a disability and manage their chronic pain. Recently the pain has been getting worse and they are having trouble taking pain medications. In the last few days, the client has also refused to eat. You have discussed this with the client a few times. You think the client is capable, however, the family is concerned that the client may be choosing to end life by refusing to eat. The client’s family is upset at the client’s declining condition and insist that they receive tube feeding. The client’s physician seems to agree with the family. When you discuss tube feeding with the client, they are adamant that they do not want to tube feeding.  What do you do?

The issue, here, is whether the client is able to give informed consent. Does the client understand and appreciate the consequences of their decision? Is it possible that another medical condition, such as depression and/or unmanaged pain, is impacting the client’s ability to make decisions?  Does the client fully understand and appreciate what is being proposed? (Please refer to the Professional Practice Standard, Consent to Treatment, Standards 1, 3-5 and 7) . If you determine that the client is fully capable of making their own decisions, then their wish to decline tube feeding needs to be respected.

This scenario illustrates the difficulties in accepting a client’s wish when this is contrary to your own practice and personal values, particularly when relatives and colleagues take a different view.  It is sometimes difficult to reconcile the principle of client autonomy, including the right to refuse treatment, especially if there are opposing views on care. The dietitian should have a discussion with the client to gain clarity. 

If the family’s concerns are valid, the dietitian may advise those who need to know within the client’s circle of care about the contemplated self-harm. However, the people advised about the client’s intent to harm themselves usually still need informed consent to intervene; from the client, if capable, and from a substitute decision maker if the client is not capable.